Total Ischemic Time Research Articles

Management of st-segment elevation myocardial infarction in comparison to european society of cardiology guidelines in alexandria university hospitals

Abstract Aim The aim of this study was to determine the major contributors to reperfusion delay in ST- elevation myocardial infarction (STEMI) patients in Alexandria University hospitals and the adherence to ESC clinical practice guidelines. Methods and results Prospective cohort of all patients presented with ST-elevation myocardial infarction (STEMI) with chest pain or discomfort between March 2020 and February 2021 in Alexandria university hospitals. A total of 436 patients were enrolled, 280 patients (64.2%) underwent PPCI, 32 patients (7.3%) had thrombolytic therapy and 124 patients (28.4%) had conservative strategy. In regard to the demographics and risk factors, the mean age of our cohort was 55.2 years. The majority were males (80.9%) and smokers (72.2%). Hypertension was a risk factor in 41.5% of our population, diabetes in 33.5%, and a family history was present in 14.2%, while 7.3% had renal impairment. The median pre-hospital delay was 360 minutes; mainly due to delay in seeking medical care which was the cause in 45.6%, whereas the mean ER time delay was 48.24 ± 89.30 minutes. The median time from CCU admission to wire crossing was 40.0 minutes with a mean value 53.86 ±49.0 minutes. The total ischemic time was 372 minutes (6.2 hours) with a mean ischemic time of 408 minutes (6.8 hours). The rate of reperfusion therapy (PPCI or thrombolysis) was 71.5 percent among all STEMI patients who presented within 12 hours, with achievement of timely reperfusion according to ESC guidelines for management of STEMI in 35.0%. The majority of our patients (70.7%) had door to wire crossing time of less than 90 minutes. In-hospital overall mortality was 5.5%. The PPCI group had a mortality rate of 2.9 percent, whereas the conservative management group had a mortality rate of 12.9 percent, with a statistically significant difference (P<0.001) between the two groups. In-hospital overall MACE was 27.3%. The PPCI group had MACE rate of 15%, the thrombolytic group had MACE rate of 28.1%, and the conservative management group had MACE rate of 54.8%, with a statistically significant difference (P<0.001) between the three groups. Conclusions Regardless of the financial and technical limitations in our center, timely reperfusion rate and performance are not far from meeting ESC 2017 guidelines for the management of STEMI. Primary PCI was the most frequently used treatment modality, and the associated total in- hospital mortality was below 5%. An enormous increase in the total ischemic time is a major concern due. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

IntroductionPatients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min. ObjectivesTo assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI. MethodsWe performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017. ResultsMedian DIDO time was 82 min (interquartile range, 61–132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062–1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011). ConclusionA DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.

Temporal trends, short- and long-term prognostic impact of pre-hospital delay times in ST elevation myocardial infarction – 20 years national data from the SWEDEHEART registry

Abstract Background Previous studies have demonstrated that total ischaemic time during ST-elevation myocardial Infarction (STEMI) is associated with mortality. However, how duration from symptom onset to hospital admission affects outcomes and how pre-hospital delay times (PHDT) have evolved over time in STEMI in total, as well as in prespecified subgroups, remains unknown. Aim The aim was to explore temporal trends and prognostic impact of PHDT in STEMI patients during the last two decades in Sweden, including the fibrinolytic era as well as the primary percutaneous coronary intervention (PPCI) era. Temporal trends of PHDT was aimed to be studied in the total STEMI cohort as well as in subgroups according to age, sex and presence or absence of diabetes. Method This was an observational retrospective cohort study based on the SWEDEHEART registry including 89,155 STEMI patients between 1998 and 2017. Results In total, the PHDT curve was hump-shaped without any significant trend. The median PHDT was 150 min (Q1 80; Q3 302), and the shortest PHDT of 140 (Q1 85; Q3 274) min was found during the last period. During the fibrinolytic era (1998–2004) there was a significant increase in PHDT while delay times decreased during the PPCI era (2005–2017). There were consistent differences within subgroups; women sought care 25 min later than men, older (&amp;gt;70 years) delayed 30 min longer than younger and patients with diabetes 29 min longer than those without. Higher short- and long-term mortality was seen with increasing delay except for the group seeking care within 1 hour, which had higher short-term mortality. In five years follow up, mortality incrementally increased with delay, from 24.1% (0–1 hours) to 31.1% (&amp;gt;12 hours) of PHDT, p&amp;lt;0.01. When adjusting for confounders the risk of dying within 1 and 5 years was approximately 1% per hour of increase of PHDT (HR 1.011, 95% CI 1.006–1.016 and HR 1.008, 95% CI 1.004–1.013, respectively). Conclusions PHDT is an independent predictor of short- and long-term mortality and reducing PHDT will diminish the risk of heart failure and premature death. We found only a modest decrease in PHDT over time and the trend was hump shaped. Since the implementation of PPCI, with the diagnosis of STEMI made in the ambulances, these have been redirected in the pre-hospital setting, transporting the patient directly to cath lab. This may explain why the PHDT initially increased in the beginning of this era when new routines were being established. Although we did not find any significant trend during the total 20-year period it is reassuring that the PHDT decreased during the PPCI era. Anyhow, there are subgroups with consistently prolonged PHDT, such as women, the elderly, and patients with diabetes, who need to be targeted in future interventions. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): This study was funded with grants from the Medical Research Council of Southeast Sweden (FORSS), Region Östergötland and Linköping University Hospital Research Fund, Sweden.

Analysis of myocardial salvage with cardiac magnetic ressonance and angiography depending on the STEMI revascularization pathway in a PPCI centre

Abstract Background Reperfusion networks have permitted improvements in reperfusion delays in primary percutaneous coronary intervention (PPCI)-treated ST elevation myocardial infarction (STEMI). However, the impact on myocardial salvage (MS) of direct transfer to the catheterization laboratory (cath-lab) to minimize system delay remains unknown. Objective We sought to quantify the myocardial salvage index (MSI) acutely and to assess adverse remodeling at 6 months in PPCI-treated STEMI according to the mode of patient presentation. Methods Between 2005 and 2021 we included 493 patients in a single center registry of first PPCI-treated STEMI who were studied with Late gadolinium enhanced (LGE) cardiac magnetic resonance (CMR) in the acute phase. Among them, 414 (84.0%) underwent a second LGE-CMR at 6 months. Subjects were classified depending on the mode of presentation: those diagnosed out-of-hospital and directly transferred to the cath-lab by the Emergency Medical Services (EMS group, 29.82%); subjects with first medical contact in a PCI-capable hospital (PCI-H group, 41.75%); and patients presenting to a non-PCI-capable center and transferred for PCI (non-PCI-H group, 28.43%). We computed the angiographic area at risk by BARI score, and combined it with the LGE-CMR derived infarct size to compute a validated MSI, expressed as percentage of area at risk. The change in ejection fraction (EF) and indexed left ventricle end-diastolic volume (iLVEDV) from baseline to 6 months was also computed. Results The mean age was 58.9±11.9 years, 84.5% were male and 51.4% had anterior STEMI. Total median ischaemic time was (median (interquartile range)) 126 (105–161) min in the EMS group, 201 (145–321) min in the PCI-H group and 300 (173–592) min in the non-PCI-H group (p&amp;lt;0.01). MSI was 45.28±2.6%, 39.63±2.2% and 35.53±2.7% respectively (p=0.034). In a multiple linear regression model adjusting for relevant covariables, including initial TIMI flow, area at risk, Killip class, age, sex, diabetes, number of vessels and presence of collaterals, a 7.50% (95% CI 0.9 to 14.1%) increase in MSI was observed in the EMS group compared to the PCI-H group, and 11.03% (95% CI 3.9 to 18.2%) compared to the non-PCI-H group (p=0.027 and 0.003 respectively). At 6 months, the mean absolute increase in EF was 5.36±0.6% for the EMS group, 4.03±0.5% for the PCI-H group and 3.52±0.6% for the non-PCI-H group (p&amp;lt;0.05 in the adjusted analysis) and the increase in iLVEDV was 2.37±7.3, 5.51±6.6 and 18.30±7.6 mL/m2 respectively (p=0.28). Conclusions Patients with out-of-hospital diagnostis of STEMI by the EMS who were directly transferred to the cath-lab showed shorter total ischaemic times, resulting in increased myocardial salvage and a trend towards improved indexes of left ventricular function at 6 months. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grant from La Maratό de TV3 and grant from Fundaciό La Caixa

First medical contact facility type as a determinant of prognosis in a regional ST elevation myocardial infarction network

Abstract Background Delay in primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infartion (STEMI) is associated with worse prognosis. In our regional STEMI network, the first medical contact (FMC) facility type defines 4 different assistance pathways (i.e. emergency medical services'diagnosis on the field and direct transfer to the catheterization laboratory (cath. lab) of a PCI hospital (EMS group); direct admission to a PCI hospital (PCI-H group); admission to community hospital and transfer to the cath lab of the PCI-H (CH group); diagnosis in a primary care centre and transfer to the cath lab of the PCI-H (PCC group). Each different FMC has been associated with different degrees in reperfusion delay. Objective To determine the influence of FMC facility type on 1-year mortality in patients with STEMI in our regional STEMI network. Methods This is a retrospective study based on the STEMI network registry, a mandatory registry conducted since its implantation and supervised by the regional health authorities. We included STEMI patients treated with PPCI from January 2010 to December 2020. We analyzed differences in clinical variables, reprefusion times and 1-year all-cause mortality regarding the FMC facility type. Results We included 18332 patients (EMS 34.25%, PCI-H 12.28%, CH 33.47%, PCC 20.01%). Initial Killip classes III–IV: EMS 8.43%, PCI-H 7.51%, CH 5.54%, PCC 3.76%; p&amp;lt;0.001. All comorbidities and complications in first medical assistance were more frequent in EMS and PCI-H groups (p&amp;lt;0.05). PCC group had the lowest risk profile regarding comorbidities and first medical assistance complications (p&amp;lt;0.05 for most of variables). The PCI-H group had the shortest system delay (median 82 min, p&amp;lt;0.001), the EMS group had the shortest total ischemic time (median 151 min, p&amp;lt;0.001). Crude 1-year mortality was EMS 8.6%, PCI-H 9.11%, CH 8.25%, and PCC 4.77% (p&amp;lt;0.001). After adjusting for several covariables with a logistic regression model, PCI-H and CH groups were associated with higher 1-year mortality compared to EMS group (OR 1.23 (IC95% 1.01–1.49; p=0.04) and OR 1.16 (IC95% 1.01–1.34; p=0.04) respectively), while PCC group was associated with lower 1-year mortality (OR 0.69 (IC95% 0.57–0.84; p&amp;lt;0.01)). Conclusions First medical contact with EMS and direct transfer to the cath lab was associated with lower adjusted 1-year mortality compared to first medical contact with a PCI hospital or a community hospital. Funding Acknowledgement Type of funding sources: None.

Early survival after acute myocardial infarction with ST-segment elevation: What could be improved? Insights from France PCI French registry

Early mortality post-ST-segment elevation myocardial infarction (STEMI) in France remains high. The multicentre France Percutaneous Coronary Intervention Registry includes every patient undergoing coronary angiography in France. We analyzed the prevalence and impact of unmodifiable and modifiable risk factors on 30-day survival in patients experiencing STEMI.Patients admitted for STEMI between 01/2014 and 12/2016 were included in the analysis. Patients with nonobstructive coronary artery disease, with cardiogenic shock or cardiac arrest without STEMI, were excluded. Prehospital, clinical and procedural data were collected prospectively by the cardiologist in the cath lab using medical reporting software. Information on outcomes, including mortality, was obtained by a dedicated research technician by phone calls or from medical records. Marginal Cox proportional hazards regression was used to test the predictive value for survival at 30 days in a multivariable analysis.Included were 2590 patients (74% men) aged 63 ± 14 years. During the first month, 174 patients (6.7%) died. After adjustment, unmodifiable variables significantly associated with reduced 30-day survival were: age > 80 years (prevalence 15%; hazard ratio [HR] 2.7; 95% confidence interval [CI] 1.5–4.7), chronic kidney disease (2%; HR 5.3; 95% CI 2.6–11.1), diabetes mellitus (14%; HR 1.6; 95% CI 1.0–2.5), anterior or circumferential electrical localization (39%; HR 2.0; 95% CI 1.4–2.9), and Killip class 2, 3, or 4 (7%; HR 3.4; 95% CI 1.9–5.9; 2%; HR 10.1; 95% CI 5.3–19.4; 4%; HR 18; 95% CI 10.8–29.8, respectively). Among modifiable variables, total ischemic time > 3 hours (68%; HR 1.8; 95% CI 1.1–3.0), lack of appropriate premedication (18%; HR 2.2; 95% CI 1.5–3.3), and post-PCI TIMI < 3 (6%; HR 4.9; 95% CI 3.2–7.6) were significantly associated with reduced 30-day survival.Most predictors of 30-day survival post-STEMI are unmodifiable, but outcomes might be improved by optimizing modifiable factors, most importantly ischemic time and appropriate premedication.

346.11: Miami Protocol for Liver Deceased Donors After Circulatory Death: Increased 1-Year Overall Survival for Selected Patients

Background: The use of deceased donors after circulatory death (DCD) for liver transplantation (LT) is still underutilized. It provides an acceptable solution to increase the organ donor pool without affecting outcomes. We analyzed data of DCD donors for LT in order to identify risk factors for graft and patient survival. Methods: This was a retrospective cohort study using data reviewed by screening SRTR/UNOS of patients that underwent liver transplantation with DCD donor at the University of Miami, Jackson Memorial Hospital in Miami, FL from 2017 to 2019. Different surrogates were analyzed, including donor, recipient, procurement and transplant operation characteristics. The primary outcome was patient and graft survival. Continuous variables were analyzed using a 2-sided student t-test. Categorical variables were presented as frequencies and proportion and compared using chi-squared or Fisher’s exact test as appropriate. Univariable Cox proportional hazards models were fit in order to assess the impact of individual covariables on the instantaneous rate of events, with time-to-event analysis also being ascertained through Kaplan-Meier estimates. Results: 54 cases were analyzed with a median MELD score of 18.5. Alcoholic cirrhosis was the most prevalent etiology for liver disease. There was 1 case with intra-hepatic biliary stricture, and 7 patients with anastomotic strictures that required stenting. The 1-year survival rate following liver transplant using DCD donors was 90.7%. The total cold ischemic time (CIT) (HR 1.9, 95% CI 1.1-3.2) and diagnosis of rejection (HR 9, 95% CI 1.1-78.8) were statistically significant affecting graft failure. Estimated blood loss (EBL) with HR of 1.1 (95% CI 1.1-1.2) was found to be statistically impacting survival rate. Conclusion: DCD donors are excellent options to increase the availability of organs for patients waiting for a LT. CIT and EBL are the main predictors of poor outcomes and thus should be carefully taken into account when matching organs to recipients.

Should doctors replace machines in prehospital electrocardiogram interpretation?

Should doctors replace machines in prehospital electrocardiogram interpretation?

1035 Gender Equality in Heart Transplantation: A Single Centre Study

Abstract Background International Society for Heart and Lung Transplantation catergoirises female gender in donor/recipient, as a significant risk factor for mortality after heart transplantation. Further, donor-recipient gender mismatch is also reported to be a determinant of post-transplant morbidity/mortality. To examine the effect of gender in survival outcomes, we conducted a retrospective study. Method Population comprised of 298 patients undergoing heart transplantation from 2001 to 2021, divided into four groups on the basis of donor and recipient matching. Group A consisted of men who received male donor-hearts, group B of women who received female donor-hearts, group C of women who received male donor-hearts, and group D of men who received female donor-hearts. Standard heart transplantation protocols were applied to all patient groups for graft preservation, surgical technique, donor-recipient size matching, induction &amp; immunosuppressive therapy. Results The study groups were found to be homogeneous to the major preoperative- risk- factors (aetiology, transplantation status, donor-recipient-age, total ischemic time). Donor gender, recipient gender and donor-recipient gender mismatching did not significantly modify the short and mid-term survivals, functional recovery, and primary graft dysfunction post-surgery. Conclusions Even though previous reports suggest that gender negatively affects survival, this proved to have no influence on the outcomes in our study. These results can be explained by a correct donor-recipient size matching. The well-documented female recipients’ tendency to more frequent and fatal rejection was not confirmed in our experience. The patient's age at transplantation, the routine use of induction therapy and an aggressive immunosuppressive regimen may be the substrate of these findings.

1036 Gender Equality in Heart Transplantation: A Single Centre Study

Abstract Background International Society for Heart and Lung Transplantation categorises female gender in donor/recipient, as a significant risk factor for mortality after heart transplantation. Further, donor-recipient gender mismatch is also reported to be a determinant of post-transplant morbidity/mortality. To examine the effect of gender in survival outcomes, we conducted a retrospective study. Method Population comprised of 298 patients undergoing heart transplantation from 2001 to 2021, divided into four groups on the basis of donor and recipient matching. Group A consisted of men who received male donor-hearts, group B of women who received female donor-hearts, group C of women who received male donor-hearts, and group D of men who received female donor-hearts. Standard heart transplantation protocols were applied to all patient groups for graft preservation, surgical technique, donor-recipient size matching, induction &amp; immunosuppressive-therapy. Results The study groups were found to be homogeneous to the major preoperative- risk- factors (aetiology, transplantation status, donor-recipient-age, total ischemic time). Donor gender, recipient gender and donor-recipient gender mismatching did not significantly modify the short and mid-term survivals, functional recovery, and primary graft dysfunction post-surgery. Conclusions Even though previous reports suggest that gender negatively affects survival, this proved to have no influence on the outcomes in our study. These results can be explained by a correct donor-recipient size matching. The well-documented female recipients’ tendency to more frequent and fatal rejection was not confirmed in our experience. The patient's age at transplantation, the routine use of induction therapy and an aggressive immunosuppressive regimen may be the substrate of these findings.

Results of anastomosis of accessory lower polar graft artery to internal iliac artery in renal transplantation

Background: Our objective is to perform a renal graft transplant using multiple arteries where the lower polar artery will indeed be anastomosed to the internal iliac artery end to side following declamping the main arterial supply in terms of ischemia time, diuresis, graft perfusion, and postoperative clinical parameters and investigations. Methods: Fifty live donors underwent vascular anastomosis of the graft auxiliary lower polar artery to recipient internal iliac artery end to side anastomosis with various renal arteries bilaterally, including lower polar artery in chosen kidney. The recipients' intraoperative warm and total ischemia periods, as well as their postoperative incidence of acute tubular necrosis, were assessed (ATN). Diuresis, urinary output, and creatinine levels at 1, 3, and 5 days after surgery, as well as at 2 months afterwards. MRI and Doppler ultrasonography, if necessary. Results: In contrast to warm, the mean total ischemia time was 20.86 minutes. Low incidence of ATN (8%) was controlled and postoperative recovery went without a hitch. Regarding postoperative urine output and serum creatinine level monitoring, clinical and laboratory indicators were satisfactory. Depending on the assessment method, colour Doppler ultrasonography reveals well perfused transplanted grafts with a satisfactory peak systolic velocity ratio in the auxiliary graft artery.

Acute Mirror M1 Occlusions Treated With Endovascular First-Pass Contact Aspiration Technique

Patients with acute bilateral M1 occlusion are usually comatose at presentation and have a grave prognosis. There have been few reports of emergent treatment using endovascular reperfusion therapy (ERT). We describe a patient treated with simultaneous first-pass contact aspiration and review the literature for cases describing the successful use of ERT in patients with bilateral anterior circulation proximal large-vessel occlusion (LVO). A functionally independent 95-year-old woman with history of atrial fibrillation (AF) presented with altered mentation, aphasia, and weakness in all extremities. Her National Institutes of Health Stroke Scale (NIHSS) score was 13. CT angiogram and perfusion demonstrated acute mirror M1 occlusions with extensive bilateral middle cerebral artery (MCA) territory penumbra, respectively. Emergent ERT was performed with simultaneous contact aspiration within the bilateral M1s under concomitant flow arrest with a balloon guide catheter. Modified Thrombolysis in Cerebral Infarction (mTICI) grades 3 and 2c were achieved on the left and right, respectively. By postoperative day 1 (POD1), the patient had improved motor function, mentation, and communication.The technical feasibility of simultaneous contact aspiration thrombectomies for acute bilateral M1 occlusions was demonstrated with successful reperfusion of both vascular territories in a single pass lasting 28 minutes. Simultaneous thrombectomies yielded rapid recanalization and reperfusion and minimized radiation exposure. Previous cases demonstrating this technique utilized stent-retriever techniques in successive fashion, with a consequent increase in the patient’s total ischemic time. The technical success of our aggressive approach suggests it may have utility in the treatment of acute multivessel occlusions (MVOs).

Outcome of primary graft dysfunction rescued by venoarterial extracorporeal membrane oxygenation after heart transplantation

Primary graft dysfunction remains the leading cause of 30-day mortality after heart transplantation. Few data have been published about the clinical outcome of severe primary graft dysfunction treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). To evaluate the prevalence and outcome of severe primary graft dysfunction requiring VA-ECMO, and to identify factors associated with hospital mortality. We performed an observational analysis of our institutional database of VA-ECMO for primary graft dysfunction after heart transplantation. Patients with severe primary graft dysfunction, according to the International Society for Heart and Lung Transplantation classification, were included. The primary outcome was survival to hospital discharge. Risk factors for in-hospital mortality were searched with multiple logistic regression analysis using backward stepwise variable elimination. Of the 397 patients who had heart transplantation between January 2007 and December 2018, 60 (15.1%) developed severe primary graft dysfunction requiring VA-ECMO. The median age was 52 (interquartile range 39-59) years, and 73.3% were male. Thirty-nine (65.0%) patients were weaned after a mean duration of VA-ECMO support of 7.2±6.0 days. Thirty-two (53.3%) patients were alive at hospital discharge. Inotropic support in the recipient before heart transplantation (odds ratio [OR] 3.88, 95% confidence interval [CI] 1.04-14.44; P=0.04), total ischaemic time (OR 0.99, 95% CI 0.99-1.00; P=0.01) and 48-hour total blood transfusion (OR 1.14, 95% CI 1.04-1.26; P=0.01) were independent predictors of in-hospital mortality. Severe primary graft dysfunction requiring VA-ECMO is frequent after heart transplantation. Survival to hospital discharge after VA-ECMO for severe primary graft dysfunction is satisfactory in such a critically ill population.

Outcomes in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention or pharmacoinvasive strategy in a Latin American country

ObjectiveThe primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). The pharmacoinvasive strategy (PIs) is a reasonable alternative when prompt PPCI is not possible, especially in resource-limited regions. We aimed to compare PPCI versus PIs outcomes in Peru.MethodsThis was a retrospective cohort study based on the second Peruvian Registry of STEMI (PERSTEMI II). We compared the characteristics, in-hospital outcomes and 30-day mortality of patients undergoing PPCI during the first 12 h and those receiving a PIs. A propensity score-matched analysis was conducted to compare the effects of each treatment strategy on clinical outcomes.ResultsPIs patients were younger than PPCI patients, had a shorter first medical contact time, first medical contact to reperfusion time, and total ischemic time until reperfusion. Successful PCI was more frequent in the PIs group (84.4% vs. 71.1%, p = 0.035). There were no differences between PIs and PPCI in terms of total in-hospital mortality (5.2% vs. 6.6%, p = 0.703), cardiovascular mortality (4.2% vs. 5.3%, p = 0.735), cardiogenic shock (8.3% vs. 13.2%, p = 0.326), heart failure (19.8% vs. 30.3%, p = 0.112), or major bleeding (0% vs. 2.6%, p = 0.194). In the propensity score-matched analysis, the rates of cardiovascular mortality, postinfarction heart failure and successful reperfusion were similar.ConclusionsIn this real-world study, no differences were found in the in-hospital outcomes between patients with STEMI who received PIs or PPCI.

Association of pre-hospital time intervals and clinical outcomes in ST-elevation myocardial infarction patients.

Study ObjectivesTimely coronary reperfusion is critical for favorable outcomes after ST‐elevation myocardial infarction (STEMI). A substantial proportion of the total ischemic time is patient related, occurring before first medical contact (FMC). We aimed to expand the limited current understanding of the associations between prehospital intervals and clinical outcomes.MethodsWe conducted a retrospective analysis of consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) (January 2009–March 2016) and assessed the associations between prehospital intervals and the incidence of new heart failure, cardiogenic shock, and hospital length of stay (LOS), adjusting for important clinical variables.ResultsA total of 773 patients (77% men, median age 65 years) met eligibility criteria. The median pre‐911 activation interval was 29 minutes (interquartile range: 11, 89); the median 911 call to FMC interval was 12 minutes (interquartile range: 9, 15). In multivariable analysis, there was a V‐shaped relationship between the pre‐911 activation interval and outcomes: a lower likelihood of new heart failure (odds ratio [OR] 0.51; 95% confidence interval [CI]: 0.30, 0.87), cardiogenic shock (OR 0.40; 95% CI: 0.21, 0.75) and prolonged LOS (OR 0.24; 95% CI: 0.14, 0.42) for midrange intervals (11–88 minutes) when compared to the early (< 11‐minute) interval. There was no statistically significant relationship between total pre‐FMC time and FMC to device activation time.ConclusionsAmong ambulance‐transported STEMI patients receiving pPCI, the shortest and longest pre‐911 activation time intervals were associated with poorer outcomes. However, variation in post‐FMC interval alone was not associated with outcomes, suggesting that interventions to reduce pre‐FMC intervals must be prioritized.

Various Techniques and Outcomes of Arterial Anastomosis in Live Renal Transplant: An Institutional Experience.

IntroductionRenal transplantation with multiple arteries is associated with a major index of surgical complications. Relevant papers and meta-analyses have shown relatively more vascular and urological complications in transplant of donor kidneys with multiple arteries. In live donor grafts due to the unavailability of a carrel patch, several techniques for bench and in situ reconstruction have been described in order to reduce the incidence of these vascular complications. In this study, the short and long-term results of living donor kidney transplants with multiple renal arteries (MRAs) versus single renal artery (SRA) were compared retrospectively.MethodsThis is a retrospective study done on patients who received a living donor kidney between January 2012 and January 2018 at the Institute of Urology, Madras Medical College, Chennai. We have excluded deceased donor kidney transplants and ABO-incompatible cases done in the same time period. The study was approved by the Institutional Ethics Committee (Approval No: IES-MMC-008) and performed in accordance with the guidelines of the Declaration of Helsinki. Open live donor nephrectomy was performed through an extra-peritoneal flank incision in all cases. In the SRA group, the renal artery was anastomosed end to end to the Internal iliac artery, while the renal vein was anastomosed to the external iliac vein in the end to side fashion. Urinary tract reconstruction was accomplished by the Gregoir technique in both groups. We looked at recipient complications, baseline and postoperative serum creatinine, total ischemia time, mean operating time, and short- and long-term graft and patient survival as postoperative outcomes.ResultsIn a six-year period (2012-2018) at our institute, 256 living donor transplantations were performed; 36 (14%) kidneys had two or more renal arteries which were anastomosed using various techniques. Cold ischemia time was relatively longer in the MRA group (45 mins vs 28 mins in the SRA group) (p-value <0.05). while warm ischemia time was comparable in both groups (2.5 vs 2.9 mins) serum creatinine was comparable in both groups at the 30th postoperative day (1.4 in SRA group vs 1.2 in MRA group) (p-value >0.05). Incidence of surgical complications in SRA and MRA groups was: vascular - 3.6% and 2.7%; urological - 3.2% and 2.7%; the incidence of lymphocele was 4.5% and 5.5% and delayed graft function 4.5% and 5.5% respectively.ConclusionMultiple renal arteries are no longer a relative contraindication with advanced surgical techniques. in renal grafts with multiple arteries, all techniques of vessel anastomosis are comparable in terms of post-surgical complications.

Packing the donor heart: Is SherpaPak cold preservation technique safer compared to ice cold storage.

The present study aimed to compare the clinical outcomes of heart transplant patients whose donor hearts were preserved with the SherpaPak controlled cold organ system versus the conventional ice storage technique. All patients undergoing heart transplantation at our center between January 2019 and April 2021 were divided into two groups according to the technique used during donor heart preservation and transport. The first group consisted of 34 SherpaPak controlled temperature preservation patients, and the second group consisted of 47 patients where the conventional three bags and ice technique was utilized during organ transportation. The two groups were compared based on demographics, operative details, and postoperative outcomes. There were no significant differences between the groups regarding Vasoactive Inotropic Score (VIS), Primary Graft Dysfunction (PGD), and the need for a transient pacer. However, the VIS, PGD, and pacing trends were lower in the SherpaPak patients even though the total ischemic and cardiopulmonary bypass times were significantly longer. Furthermore, SherpaPak patients exhibited a shorter stay in the ICU with no severe PGD and mortality. The SherpaPak donor heart preservation provides safe outcomes in heart transplant patients. Further research is needed to utilize this method for longer durations of ischemic time and expand travel distances for organ transportation.

P36 THE ELDEST HEART TRANSPLANTED PATIENT IN EUROPE: 36 YEARS SURVIVAL AND STILL GOING ON

Development of endomyocardial biopsy for acute rejection monitoring in the early Seventies, and above all use of cyclosporine in the clinical practice starting from 1980, introduced the modern era of heart transplantation. Following the initial positive outcomes, the first Italian transplant was performed in Padua by V.Gallucci on November 15th 1985. This pioneering success was rapidly repeated in Pavia, where M.Viganò performed the second transplant on Novembre 17th. Recipient was 20 years old man, suffering from dilated cardiomyopathy, on urgent transplant list. Cardiac index was 1.38 l/min/m2 and pulmonary vascular resistance 1.6 WU. Donor was a 14 years old boy died of brain injury. Total ischemic time was 125 minutes. Induction immunosuppression consisted of horse anti–lymphocyte immunoglobulins, whereas maintenance therapy included cyclosporine, azathioprine and steroids. Postoperative course was complicated by pericardial effusion and cholestatic jaundice. Later pulmonary aspergillosis occurred and due to the profound immunodepression was complicated by fungal localization at L2 vertebral body. The infection was treated with surgical removal of the secondary localization and amphotericin B administration. On December 6th severe acute rejection was found at biopsy and treated with i.v. steroid pulse. Length of ICU and hospital stay was 28 and 72 days, respectively. In 1998 HCV infection was detected and eradicated in 2017 with elbasvir/grazoprevir therapy. Complications of long term immunosuppressive treatment included dyslipidemia, myeloma and basal cell carcinoma. Due to long–term calcineurin inhibitors therapy progressive chronic renal failure occurred, leading to replacement therapy in 2015 and kidney transplantation in 2016. In 2015 the patient underwent percutaneous coronary intervention with stents implantation in two marginal branches and in the anterior descending artery in 2021. Everolimus was introduced to slow down progression of cardiac allograft vasculopathy. In 2020 he suffered from Covid–19, but the course of infection was uneventful being cough the only symptom. We report the eldest survivor after heart transplant in Europe. Our case demonstrates that despite early and long–term complications of immunosuppressive therapy, a careful and patient tailored management allowed an amazing outcome. Nowadays heart transplant remains the best treatment for end stage heart failure and allows to resume a nearly normal quality of life.

Association between the level of high-sensitivity troponin I (Hs-Trop I) and major adverse cardiovascular events in patients with acute myocardial infarction of segment elevation (STEMI) with primary percutaneous coronary intervention (PCI)

ST-segment elevation myocardial infarction (STEMI) is a condition which increases the risk of developing major adverse cardiovascular events (MACEs). For patients with STEMI, an efficient method of risk stratification is necessary in order to evaluate the clinical outcome. Troponin has been commonly used in the diagnosis of both STEMI and NSTEMI. The use of high sensitivity assays of troponin has been extensively studied in order to measure the size of myocardial damage caused by STEMI. This study aimed to investigate the association between the level of high sensitivity troponin I (Hs-Trop I) and the incidence of MACEs in patients with primary percutaneous coronary intervention (PCI) in Dr. Sardjito General Hospital, Yogyakarta, Indonesia. It was a cross-sectional observational analytic study involving a total of 195 patients. Data were obtained from both the SCIENCE (Sardjito Cardiovascular Intensive Care) registry and the medical record of Dr. Sardjito General Hospital. Pearson’s Chi square test to evaluate the association between variables was applied. To determine the effect of confounding variables, a multivariate analysis was used. A significant difference in the baseline characteristics between the supramedian and inframedian Hs-Trop I groups (cutoff value of 2063.8 ng/mL) in age, onset, total ischemic time, wire crossing time and the smoking history of both groups was observed. Bivariate analysis showed a significant associations between Hs-Trop I and MACEs (p = 0.033), acute heart failure (p = 0.009) as well as mortality (p = 0.024). Meanwhile, no significant association between Hs-Trop I and cardiogenic shock (p = 0.977) and malignant arrythmia (p = 0.551) was reported. Furthermore, multivariate analysis showed Hs-Trop I, age and wire crossing time were significantly associated with the incidence of MACEs (p = 0.045). In conclusion, there is a significant association between the Hs-Trop I levels and the MACEs events in STEMI patients with primary PCI in Dr. Sardjito General Hospital, Yogyakarta, Indonesia.

Impact of the Total Ischemia Time on No-Reflow Phenomenon in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

BackgroundNo-reflow phenomenon after primary percutaneous coronary intervention is a common condition affecting the outcomes; therefore, studying its predictive factors is helpful in identifying patients at high risk. Our objective was to investigate the impact of the total ischemia time on no-reflow phenomenon and its correlation to thrombolysis in myocardial infarction flow grade after primary percutaneous coronary intervention.MethodsThis study was conducted on 545 patients with ST-elevation myocardial infarction who underwent PPCI; the patients were divided into two groups according to the incidence of no-reflow, TIMI flow ≤2 was considered no-reflow. The time interval from chest pain onset to balloon dilatation was assessed and correlated to thrombolysis in myocardial infarction flow grade.ResultsThe incidence of no-reflow was 13.9%; thrombolysis in myocardial infarction flow ≤2 occurred in 76 patients. Multivariate regression analysis showed that advanced age >65 years, the total ischemia time ˃6 h, high thrombus burden, and cardiogenic shock were the independent predictors of no-reflow phenomenon. Spearman’s correlation analysis showed a significant negative correlation between the total ischemia time and thrombolysis in myocardial infarction flow grade (r = −351 and P-value = .001).ConclusionThe time delay is the main limitation of achieving thrombolysis in myocardial infarction 3 flow after primary percutaneous coronary intervention. The total ischemia time has a significant negative correlation with thrombolysis in myocardial infarction flow grade after primary percutaneous coronary intervention.